Addiction Doctor Defends Unconventional Approach

Dr. Michael Schorsch works with opiate addicts. He was disciplined recently by the Vermont Medical Practice Board for his documentation practices. “I have spent too much time treating patients and not enough time treating their charts,” he said. (Valley News - Libby March) Purchase photo reprints »

Lebanon — There is no receptionist at Dr. Michael Schorsch’s office and the greeting visitors sometimes receive is a few sniffs and perhaps a tongue lick.

“They’re my security,” Schorsch quipped one Friday around noon, gesturing to two large German shepherds that keep him company in his second-floor office on the Lebanon green.

Exactly what Chaco and Kaia would be guarding, Schorsch doesn’t say. His practice, Mental Health Alliance, is a solo enterprise furnished sparingly with a few black cushioned chairs in the waiting room, a matching sofa in the exam room and some plants here and there.

Dressed in jeans and a blue button-down shirt, and wearing gray stubble on his chin, Schorsch prefers to keep things casual.

After 34 years as a health care provider, the Queens, N.Y., native has shed all pretense and runs his practice the way he sees fit. That includes bringing his pets to work.

The dogs are mild mannered, though their large size could be intimidating for some people. They surprised Marleen, a 55-year-old patient of Schorsch’s, when she first met them years ago. But she’s come to believe the dogs complement the care Schorsch provides.

“I think their presence makes the caregiver seem more human in light of what people are seeking help for,” said Marleen, who asked that her last name not be used in order to protect her privacy. “For a lot of people, it brings comfort.”

Unorthodox though his practice may be, Schorsch’s patients believe there is method to his madness. They also say he has opened his door to people struggling with a problem too few physicians are willing to tackle — opiate addiction.

Schorsch has earned the loyalty of patients but riled Vermont medical licensing officials who insist that his documentation practices, or lack thereof, have fallen below state guidelines.

He said the board overreached its authority and is demanding a level of documentation that is not only unnecessary for treating patients, but may even present a barrier to the doctor-patient relationship.

It’s not unusual for physicians to complain about the administrative burdens of the job. But what distinguishes the 62-year-old Schorsch from his colleagues is the extent to which he has rejected the state’s guidelines and risked his professional status to do so.

“There have been no allegations that patients have been harmed, no allegations that anybody could’ve done a better job,” Schorsch said. “Simply that I was either unwilling or refused to do the documentation that they say is appropriate.”

He also practices in a field surrounded by controversy.

Opiate addiction is an exploding problem in the Twin States tied to abuse of prescription pills such as Oxycontin and Percocet, as well as recent reports of surging heroin use. It has been identified as a major public health concern in both Vermont and New Hampshire, and the number of people needing and not receiving treatment for drug use has stayed consistently above national averages, according to the U.S. Department of Health and Human Services.

Here in the Upper Valley, Schorsch believes the problem to be particularly acute, fed by a lack of doctors to treat opiate addicts and abundance of painkillers sold illegally on the street.

Schorsch has made it his mission to plug the gaps in care, but subjecting his patients to regular drug tests, as the state wants him to do, or calling them in for “pill counts” is not only burdensome, it does nothing to help them get better, he said.

“What these people (on the board) don’t understand is that this is a chronic, lethal, relapsing disease and relapses are the nature of this disease,” Schorsch said. “(The board members) work is based on a set of standards. I work based on reducing the harm that the patient is doing to themselves.”

A Different Kind Of Practice

Schorsch hasn’t always treated people with addictions. He used to care for children.

After graduating from the Albert Einstein College of Medicine in Bronx, N.Y., in 1979, and completing his subsequent residency at Dartmouth-Hitchcock Medical Center, he opened a practice in Lyme and later in Orford. But in 1995, after more than a decade of “rashes, runny noses, vomiting, school problems, parent issues” and the like, he needed a change. Pediatrics, he said, had little else to teach him.

“If I’m not being challenged by what I do, it’s hard not to get into the kind of going through the motions routine of it,” Schorsch said.

It was life-changing year for Schorsch in more ways than one. His now-ex-wife, also a physician, was going to begin a fellowship in Dallas that summer. Schorsch began to close down his pediatrics practice so that he could move with her and their two sons to Texas. Around the same time, he was dealing with issues related to his own drug use.

Schorsch had been using marijuana for a couple of years and his wife convinced him to seek help. When it came time to renew his New Hampshire license, Schorsch voluntarily disclosed to the medical board that he was in treatment. Vermont’s medical board later got involved and the settlement agreements he reached with both states allowed him to keep his licenses as long as he met certain conditions, including getting counseling and attending group therapy meetings.

The experience altered the direction of his career.

“The time that I spent in treatment, I learned a tremendous amount about drug addiction,” he said. “When I came out of treatment, I decided number one, that I was tired of seeing diarrhea and rashes in kids … and decided that this was sort of a sign from above that a career change was indicated.”

While in Texas, he got trained in addiction medicine. Dallas offered him ample opportunities to learn. He worked with thousands of patients who were detoxing, treated psychiatric patients, and served as medical director of an inpatient treatment center for women and their children.

He spent five years in Texas. But Schorsch did not like Dallas and, after he and his wife divorced in 1998, he moved back to Orford in 2000.

As he developed his practice in addiction medicine, Schorsch became convinced that the growing volume of documentation being asked for by state medical boards was not improving patient care. It was harming it.

“The degree of documentation that they expect is not only useless, unsubstantiated scientifically, puts a barrier between me and the patient in terms of trust, sucks up a bunch of my time, but on top of everything else, it doesn’t provide any useful information or direction in terms of caring for the patient,” he said. “When all the paperwork is done, it’s still you and me and who’s telling the truth here.”

His opinion isn’t shared by the Vermont medical board.

Last month, the board determined that Schorsch failed to properly document his treatment of nine patients receiving buprenorphine (also known as Suboxone), a drug used to alleviate withdrawal symptoms for people trying to quit heroin and other opioids.

Buprenorphine is similar to methadone, in that both are synthetic opioids used to treat addiction. But buprenorphine is more difficult to abuse because it blocks the effects of other opiates, such as heroin. Methadone, meanwhile, can be used on top of other opiates to create an enhanced high, and is a highly regulated drug dispensed at treatment centers such as Habit Opco in West Lebanon.

Schorsch considers buprenorphine a “miracle drug” that needs to be much more widely available than it is. His desire to expand its use to more people who need it is why he found himself treating so many patients, which at one point was close to 100, the maximum allowed under federal law.

Schorsch didn’t object to the documentation just because he was busy with too many patients, he said. He felt the board’s expectations were unreasonable.

“The decision to back off on the documentation had nothing … to directly do with increasing my patient load,” he said. “It had to do with the experience I had obtained that allowed me to conclude that this was unnecessary and an obstacle to the time that I needed to spend with each patient.”

The board determined that Schorsch did not perform comprehensive physical exams of patients, administer urine drug tests or get written treatment agreements from them, as called for in state guidelines for care.

Schorsch said the guidelines are vague and impractical to effective treatment of patients with opiate addictions. Following the documentation practices would take up half of a 45-minute visit, he said. He’d rather spend that time taking “problem-focused, very terse, complete, efficient” notes and talking with patients.

“What (the board) essentially did was they determined that I was spending too much time taking care of my patients and not enough time taking care of my patients’ charts,” he said. “That’s the crux of it.”

Urine tests have been one area of contention. Schorsch has no philosophical problem with drug screens nor does he refuse to do them. But he said he believes that they are being used improperly.

“What I don’t do is do them for the reasons that (the board members) use and that is so that I can catch you lying so that I can exert the power over you about whether or not you get help,” he said. “This is about control.”

A “successful practicing drug addict” can get around a drug test, Schorsch said. Plus, the tests cost money, and his patients “don’t have $40 or $50 kicking around for a drug screen every time their honesty needs to be challenged,” Schorsch said.

But, said David Herlihy, the executive director of the Vermont Board of Medical Practice, there are good reasons for why regular drug screens and extensive documentation is necessary.

One is to ensure the safety of the patient. If a doctor gets hit by a bus and another doctor has to take over that patient’s care, it is important that the new doctor know as much as possible about how that patient was being treated, he said.

“In general, documentation is a critical part of care and it’s not just an administrative requirement,” said Herlihy.

Physicians are not required to follow all the recommendations for prescribing buprenorphine, Herlihy said. Nothing is mandatory. But there is an expectation that physicians honor the spirit of the guidelines in establishing a standard of care.

“In any given case, all of the safeguards are not mandatory,” Herlihy said. “But failure to use all of them clearly fall beneath the standard of care.”

The board’s investigation lasted more than two years. Throughout it all, Schorsch remained adamant that the board had unreasonable expectations for documentation.

In March, Schorsch told the board’s hearing committee that “he would reject any requirement that he take a ‘refresher course’ or submit to ‘peer oversight,’ ” according to the written decision.

Schorsch was in a position to argue. Regardless of the state’s action, he’d suffer no practical consequences. He’d already decided not to renew his Vermont medical license.

For most of his career, Schorsch has held medical licenses to practice in both Vermont and New Hampshire. To treat patients, he only needed one. Amid the investigation, Schorsch decided not to renew his Vermont license last November.

Not long after the Vermont board began investigating him on allegations of “unprofessional conduct” in September 2010, New Hampshire’s board opened its own investigation. On Dec. 15, 2011, the New Hampshire board issued its decision. It found “technical violations,” but allowed Schorsch to keep his license because he “demonstrated a commitment to curing these defects.”

Schorsch has scaled back his practice to allow for more time with patients, going from 90 people before the issues with the Vermont board began to around 25 now. But he is adamant that, even when he was handling a larger caseload, the quality of care never suffered. The decisions he has made not to do some things, such as pill counts or regular urine tests, were made with the patients’ best interests in mind, he said.

Other health practitioners disagree that there are overly burdensome documentation requirements.

“I think that the documentation requirements for medical, legal reasons really aren’t any different from the documentation requirements for any other medication,” said Ben Nordstrom, director of addiction services at Dartmouth-Hitchcock Medical Center. “The (Drug Enforcement Administration) has a legitimate concern about diversion (of drugs for unauthorized uses). And the DEA has a legitimate concern that this medication could spill out from the people for whom we’re providing care to the community and that people could sell these medications and then these medications just leech out and become another substance of abuse.”

Opiate Abuse Problem

One point on which Schorsch and his colleagues agree is that there is a severe opiate addiction problem in the Twin States.

Vermont and New Hampshire rank among the highest states for rates of illicit drug dependence and abuse among individuals age 18 to 25, according to the U.S. Department of Health and Human Services.

“It’s definitely a real problem in the area,” said Nordstrom. “The prescription opioid abuse problem is something that has been increasing over the past 10 years in the country and certainly we see that in the Upper Valley as well.”

Schorsch said he believes the problem is particularly acute in the Upper Valley, where an ample supply of prescription painkillers move through large health care facilities such as DHMC and the VA Medical Center.

Nordstrom rejects that explanation.

“I think it would be a little unfair to look at any one place and say that they are the fountainhead of the problem,” Nordstrom said. “Because the prescribing of these drugs has increased astronomically across the country.”

Nordstrom’s colleagues at the VA agree that, while opiate abuse is a problem in the Upper Valley, it is no worse here than elsewhere. They also say that the VA does everything it can to prevent the drugs from being sold on the street, including conducting pill counts and drug screens while offering complementary therapy services to help a person overcome his or her addiction.

“We do take prescribing opiates very seriously,” said Hugh Huizenga, a physician at the VA.

When it comes to treating the problem, however, a challenge has been getting patients access to the addiction specialists who can help them. Vermont and New Hampshire are above national averages in the rates of people who need treatment but have been unable to receive it, according to the U.S. Department of Health and Human Services.

Vermont has been rolling out a “hub and spoke” model to boost access for opiate treatment. In the plan introduced two years ago, specialty treatment centers serve as a “hub” for an array of community services, or “spokes,” aimed at helping a person overcome addiction.

An addict would go into one of the hubs, where an addiction expert would assess him and recommend treatment. Then, depending on the treatment plan, he would be referred to one of the spokes for care. The spokes could be primary health centers, independent physicians or specialty outpatient clinics. Two of the state’s five planned hubs are open, and others will come online later this year.

The situation in New Hampshire is less defined. A task force began meeting last year to develop a strategy for addressing the prescription drug problem in New Hampshire, including the availability of treatment.

Meanwhile, Schorsch’s patients say they would never have been able to get buprenorphine treatment if not for him.

“If I hadn’t met this man, I’d be dead right now,” said Joe, a 44-year-old patient in New Hampshire, who asked that his full name not be used to protect his privacy.

Patient Access

Schorsch has been offering buprenorphine treatment since 2002, when it became legally available in the U.S.

Currently, 43 physicians in New Hampshire and 32 in Vermont prescribe buprenorphine, according to the U.S. Department of Health and Human Services. But the number of patients physicians can take is limited by federal law, and patients say they often find themselves searching far and wide for a doctor who is accepting new patients.

Patients interviewed for this story did not want their last names, and in some cases their hometowns, revealed to protect the privacy of their medical information. They also feared the negative consequences on their jobs and lives if their coworkers and neighbors discovered they were being treated for opiate addictions.

Bob, 60, has been seeing Schorsch since 2007, but he has struggled with addiction since he was a teenager. It started with heroin and evolved into a dependence on Vicodin.

His journey to recovery was “a roller coaster,” vacillating between years of sobriety and relapse. There was another doctor who was treating him with buprenorphine before Schorsch, but the treatment wasn’t aggressive enough, he said.

“He prescribed it in a diminishing manner,” Bob said. “Starting and stopping to get me through withdrawal.”

It wasn’t working, Bob said, and the doctor ultimately wrote him off as a “hopeless case.” He learned about Schorsch through a mutual acquaintance and found the Lebanon doctor a refreshing change. “His approach was, let’s make this work,” Bob said. “(Schorsch said,) ‘You can be honest with me. I won’t cut you off.’ His approach was more humane.”

Joe, the 44-year-old patient, has been seeing Schorsch for six years. He suffers chronic back pain and had become addicted to Oxycontin for years before he sought help. Before he found Schorsch, he searched the Upper Valley for doctors who would take him. No one would. He has insurance through Medicare and Medicaid, which not every physician accepts because of the relatively low reimbursement rates.

Joe expanded his search to the New Hampshire Seacoast, and then outside of the Granite State.

He finally found a doctor in Biddeford, Maine, who would treat him. But then he calculated that it would cost him $1,000 a month to travel there for his medication. Joe decided he couldn’t afford it, but he also knew that he couldn’t afford to go without Suboxone. “Without it, I can’t function, period,” he said.

When he found Schorsch six years ago, Schorsch was not accepting new patients. Joe begged him to take him. Eventually, Schorsch acquiesced.

Schorsch gets these calls regularly. His voicemail message tells callers up front that he is not accepting new patients. But he occasionally agrees to take on someone if he believes he or she has a compelling need and treatment will make a difference.

Often, the new patients are women because there is almost always a child involved, he said. By helping her manage her addiction and get her life back on track, Schorsch reasons, he is actually saving two lives.

Marleen does not fit the stereotype of an addict. Her family lives a middle-class lifestyle in the Upper Valley. They own a home. Her husband is a small business owner and she worked as a nurse for 23 years.

More than 10 years ago, she became addicted to Percocet, which she was prescribed when she had three OB/GYN surgeries in a year. Later, her addiction included morphine, too.

She tried to manage by herself, but the cravings overwhelmed her. Her family has a history of addiction and she believes that the disease was merely waiting to take hold. “I think it was lurking there, waiting to latch on to me,” Marleen said on recent afternoon in her home. “It’s kind of insidious.”

She reported the problem to her employer as well as the New Hampshire Board of Nursing, which required her to see a counselor in order to keep her nursing license.

But she continued to struggle. When she confessed this to her counselor and asked for help, the counselor referred her to Schorsch. She has been seeing him since 2002, paying out of pocket for her treatment. “I really believe he’s a good doctor,” Marleen said. “I really believe he cares about what he does, the people he treats.

“He is trying to make a difference in the Upper Valley.”

Quality of Care

Schorsch’s patients are aware of his conflict with the state of Vermont. Many have written letters to the state medical board on his behalf.

The letters mention challenges in getting treatment while they were waitlisted at other addiction centers in the state. Others defend Schorsch’s unconventional methods and say he is the only doctor who has been able to help them successfully manage their addictions.

In interviews with patients, all said they felt comfortable with the level of care he provided and believed his casual approach actually benefited their relationship.

“He was really the type of person who was really caring and sat down and listened to what you had to say,” said Ronny, a 41-year-old patient. “He wasn’t just take a note and move on. He really listened.”

During appointments, Schorsch was able to refer back to things Ronny said previously, sometimes a year or more prior. He was never vague, either.

“He was always very specific in his details,” Ronny said. “He was very capable of replaying of what you had gone over in months and years before.”

Ronny dealt with alcohol and drug addiction for much of his life. For 10 years, he drank half a gallon of coffee brandy a day. Then he began taking Percocet, Oxycontin and eventually heroin.

Before he met Schorsch, Ronny said he’d never been able to hold a job for more than a year. He was 36 at the time. Now, he has been working a steady job in health care for two years. He has a wife, whom he met after getting clean. He credits Schorsch with helping him turn around his life.

“This man is a very committed doctor,” Ronny said.

Marleen, Bob and Joe also said they had no doubts about Schorsch’s ability to care for them, nor were they concerned about his documentation practices. Marleen said Schorsch’s easy manner is part of what makes him a good doctor. If he were taking notes all the time, she said, the quality of care wouldn’t be the same. Her other doctors seem always to be typing on a laptop, she said. Schorsch just talks with her.

At first, Marleen was intimidated to meet him, she said. He is physically imposing and speaks loudly. But his lack of pretense put her at ease and allowed her to speak candidly about her addiction.

“He didn’t just sit there, shake his head and write. He talked to you,” she said. “He really wanted to know what made you tick.”

His office, too, is more inviting than walking through the large front entrance at DHMC, she said.

This is no small matter, she said. People trying to cope with addictions are frightened and vulnerable, and any obstacle between themselves and walking through the door of a doctor’s office could be enough to prevent them from getting help.

The intimacy of Schorsch’s small, “grungy” office is welcoming in a way that a hospital could never be.

“When people are in despair, I think it’s a safe place to go,” Marleen said.

Were Schorsch not practicing, Marleen said, she doesn’t know where she would get her medication. She’s made inquiries with one other doctor, who was not accepting new patients.

When he turned 62 earlier this year, Schorsch said he seriously considered retiring. But then he couldn’t imagine what retirement would look like. There is no future for him that doesn’t involve helping people who are needy, he said.

And the people struggling with opiate addiction in the Upper Valley seem to need him, he said.

“If I won the lottery today and didn’t need to earn another dime, I’ve got a lot of things to do at home,” he said. “But it would not be possible for me to just thin brush and split wood and paint my home without having this doctor-patient thing.”

To the Editor: The Valley News is to be commended for the recent article and editorial that focused on the opioid abuse epidemic in the Upper Valley and across the U.S. (“Addiction Doctor Defends Unconventional Approach,” June 23). Especially useful for the public is the identification of those in a position to answer questions. Dr. Ben Nordstrom, director of addiction …